News stories of calamitous obstetric outcomes have recently drawn public attention to the problem of maternal mortality, a topic to which attention is long past due. While the Centers for Disease Control and Prevention reported that neonatal deaths in the United States dropped by 15% from 2005 to 2014, maternal mortality rose from 18.8 to 23.8 per 100,000 births between 2000 and 2014 (MacDorman and colleagues, Obstetrics and Gynecology, 2016). Studies indicate this is largely the result of chronic conditions, high rates of poverty, and lack of access to care. Poor outcomes for black women far outstrip those of any other race. Media coverage has focused blame on overmedicalization, such as induction of labor, extensive monitoring, and surgical deliveries, potentially alienating those women who require the greatest care.
This conundrum exists because in public narratives, intervention and prevention are interwoven in ways that lead to a blurring of risks and rights, dependence and autonomy. Data suggest that obstetric patients treated in hospitals have worse outcomes and undergo more medical interventions than those who deliver at birth centers or home: increased epidural use, episiotomies, vacuum/forceps extractions, neonatal ICU admissions, blood transfusions, cesarean sections. But such data are misleading, as sicker patients are treated in acute settings. Furthermore, many patients seen in acute settings may have had little or no prenatal care, have complex/multiple conditions, and come to hospitals in emergent states.
The prevention/intervention dichotomy profoundly affects practice. Our fear of intervention can lead to the belief that heroic, high-risk vaginal births are preferable to a surgical delivery. This can influence treatment decisions, pain management, and attendance to unforeseen emergencies in low-risk labors. It also leaves many convinced that “natural” childbirth in the hospital is impossible.
The expectation is that natural childbirth is a choice; but history reveals that vaginal delivery is not a possibility for all women. Social inequity, health disparities, and historical trauma profoundly influence maternal outcomes, as do distrust and avoidance of a medical system borne of our nation's ignominious racial history.
It is too often the case that, while we are working toward the prevention of poor outcomes and the inclusion of patients in decision-making processes, the view that intervention always has illegitimate, intrusive intent confuses the understanding of what constitutes “good” care. We leave patients feeling angry and betrayed if our effort to prevent bad outcomes is understood as a restriction of a woman's rights, a cooptation of birth, and a disruption of the rite of passage to motherhood.
Our understanding of high/low risk, choice/acquiescence, prevention/intervention dichotomies is further complicated by the racism that remains entrenched in medicine, by appalling high-profile narratives, and by inferential expectations of the birth process. As obstetric nurses who consistently have the most contact with patients, we try to give everyone tools to make informed decisions. When urgent situations arise, decisions that seem abrupt are typically not made in haste. If an outcome is tragic, patients and families ask why we didn't do more. As conscientious providers, we are often left asking ourselves the same questions.
Efforts to prevent poor outcomes should not be mistaken for unnecessary medical intervention. It is disheartening that obstetrics has become the singular area of health care where preventive medicine is shunned as counter to choice. Unfortunately, it is here that we have the most to lose.